• Dr Sally Ayesa

Benefits of reporting

Updated: Mar 31, 2019

Reporting as much as you can, as early as you can sets you up to not only be a better candidate, but a better radiologist.

After my exams, one of my most influential consultants shared with me that traditionally, the best prepared and performing Part II radiology candidates were those who reported the most studies and shouldered more of the workload around the department.

This seems like common sense, but it is often one of the fundamentals that is missing among candidates. While my department had a strong supply of plain films coming my way (as it was covered within the after-hours reporting load), other colleagues I have spoken to mention that they have little or limited access to supervised plain film reporting. On the other hand, my access to MRI reporting was less forthcoming and I had to make a concerted effort to get the experience reporting this modality.

As someone who has worked with multiple candidates, I do believe that it shows through who has had adequate and rounded reporting experience. Thoracic imaging being my area of interest, I can usually get a feel of who has reported thousands of chest x-rays and those who have predominantly worked through the modality in textbooks, tutorials and case libraries. Remember - the end game is not to pass exams, it is to become a radiologist.

You are comfortable using the correct language for the modality

Each modality has a slightly different reporting lexicon. Ideally, by the time you are sitting in the chair on viva day you should be fluent in the language of plain x-ray, CT, MRI, ultrasound, mammography and fluoroscopy. If you describe an MRI findings in terms of hyperdensity, rather than hyperintensity for example, you are going to detract from your overall impression. The examiners are going to start asking themselves exactly how many MRI studies you have reported in practice, and indeed whether you are ready to be a radiologist in the community.

The breast imaging viva is one of the most important examples of where having the terminology down is paramount to performance. A consultant colleague advised me that one of her great frustrations with giving tutorials is that candidates do not understand how to describe mammograms, for example calcifications. A trainee who sits down and identifies branching, pleomorphic linear calcifications straight out the gate will be in a much better position than someone who fumbles around and gives a vague or inappropriate description. Being able to calculate the quadrant or o'clock quickly will also improve your presentation style.

You develop and reinforce a search pattern

When I had secured my first accredited training position, but hadn't started working as a radiology trainee, I was given a very valuable piece of advice - read Felson's Principles of Chest Roentgenology. So I diligently ordered the book and opened it up. Initially sceptical - as it had some corny question and answer type interactions in the margin - I ended up eating it up in the space of a day. The most important thing I learned, however, was my search pattern for chest x-rays. I started with a system for looking at all edges of the film and my chances of finding the salient abnormality had dramatically increased.

I have developed this skill over years, and now my CXR search pattern is at brainstem. It is so finely practiced that I can work quickly and efficiently, without having to think about it. This is ideally the level you should be at in vivas. You don't want to waste more time than you have to "taking a moment to review the images" - as I so often hear candidates say in their viva presentations.

For the harder cases, where there are multiple overwhelming findings (or alternatively when you can't find a finding at all), you need to be able to call upon you tried and tested search pattern to help you work it out. In the exam setting, you are exhausted, stressed, wired and frantic - and if you haven't honed and practiced your technique you will drown quickly. One of my most frequent pieces of advice to candidates in this setting is to just pretend this is a busy overtime shift and a complex trauma patient has come across the reporting pile. Just take a breath, and move through one organ at a time in sequence until it all starts to come together - and it will.

You pick the abnormality faster

If you have reported thousands of chest x-rays, your eye is automatically going to be drawn to the abnormality as it just won't seem right. This is especially true in review area cases where the finding may be a subtle hilar enlargement, or a retrocardiac pulmonary opacity.

The quicker you find the abnormality, the faster you can analyse and manage the case and move onto the next one!

Pick up the microphone and get reporting!

You screen for associated findings automatically

Reporting experience isn't just about picking abnormalities. One of the major differences between a first year and a final year trainee is the degree of synthesis provided in a report. Junior registrars are more likely to focus on identification and description, leaving a larger amount of clinical correlation and management decisions arising from the imaging in the hands of the clinicians. As you grow as a radiologist, your role in the diagnosis and management of patients takes on a different shape.

Take for example a female patient in her 20s who presents with severe right lower quadrant abdominal pain and diarrhoea. She has a CT scan which shows terminal ileitis. A more junior trainee will describe this and give an appropriate differential list including Crohn's disease, infection etc. A more senior trainee will know to look for the associated findings, as there may be more value to add. So they look for other areas of inflamed small bowel, sacroiliiits, effusions around the hip joints and biliary dilatation. In life and vivas, being considered in your approach and able to screen for the whole picture will see your colleagues look upon you and your body of work favourably.

You become better at identifying and dismissing incidental or irrelevant findings

Examiners are now advised that they cannot offer prompting in a viva setting, which means it is potentially much easier to get lost in a downward spiral of your own making. An incidental finding which is misinterpreted can often be the cause of this, and can give examiners a big clue that the candidate in the chair in front of them may not be sufficiently prepared.

Take a simple example - an azygous fissure on a CXR. A good candidate will identify and dismiss the variant - "an incidental azygous lobe and fissure is noted" - before moving on to a more significant/salient finding. A less prepared candidate may get lost in a debate about the significance of the finding and whether this is perhaps a vascular anomaly and whether this could contribute to haemoptysis and whether every other subtle aberration on the film is another vascular anomaly and whether this patient could have HHT. Phew. All the while they have missed the destructive rib lesion which was the crux of the case.

A final tip....

Pick up the microphone. Sure, there is an argument to be had that typing in the lead up to film writing has some merit, but far and away you want to be articulating your findings as much as you can. If the only time you are describing out loud is in vivas, you will struggle. But if you are putting 'stops' and 'commas' in your viva presentation - you are on the right track!

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